HospitalInspections.org

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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 482.13, PATIENT RIGHTS, was out of compliance.


A-131 The facility failed to ensure 1 patient (#7) representative was notified of an incident that involved the patient and had the potential to effect treatment and potential outcome. This failed practice denied patients and/or their representatives the ability to make informed choices about patients care and safety at the facility.


A-144 The facility failed to ensure adequate staffing and/or training to provide one to one monitoring (1:1-one staff assigned to one patient with direct supervision) and every 15 (Q-15) minute checks to ensure a safe environment for 4 patients reviewed (#s2, 3, 5 and 16), with an identified risk of assaultive and/or violent behaviors against themselves and/or towards others, suicidal and/or self-harming behaviors, and failed to prevent access to objects that patients could use to harm themselves and/or others. These failed practices placed patients at risk for harm from due to lack of supervision.


A-168 The use of seclusion must be in accordance with the order of a physician or other independent practitioner. The facility failed obtain verbal orders that identified the type of seclusion and/or verbal restraint for 3 patients (#7, 9, and 11). These failures created a risk for patients being placed in restraints and/or seclusion without a physician determining the appropriateness for each restraint episode.


A-175 Staff must be trained assess patients placed in restraint and/or seclusion through evaluation and surveillance of the patient's reaction to the intervention. The facility failed to ensure unlicensed staff (mental health specialists) had been provided training to implement components of seclusion delegated by registered nursing staff for 4 patients (#s7, 8, 9, and 11) in seclusion. This failed practice placed patients at risk for an ineffective assessment of seclusion interventions and a failure to recognize psychological and/or physical harm.



A-178-The facility failed to ensure staff conducting the 1-hour face to face assessment following seclusion implemented for 5 patients (#s 7, 8, 9, 11, and 14) was not performed by a Qualified Registered Nurse that had been trained and demonstrated competencies in the facility's seclusion policies. This failed practice placed psychiatric patients at risk for unrecognized trauma and/ or harm and potential subsequent disruption to therapy from the use of seclusion.


A-182 The facility failed to ensure the on-call physician, and/or other independent practitioner was notified of the results of the face-to-face assessment. This failed practice placed 5 patients (#7, 8, 9, 11, and 14) at risk for not having a physician review any findings from the face-to-face assessment.


A-196-The facility failed to ensure staff assigned to patient care responsibilities had completed competencies in the application, implementation, and monitoring of patient seclusion. This failed practice placed all patients in the hospital with potential histories of trauma, depression, and mental illness at risk for harm from injurious behavior and/or psychological harm.


A-205 The facility failed to ensure clinical staff implementing seclusion were trained and had competency in monitoring psychiatric patients in seclusion. This failed practice placed 5 patients (#s7, 8, 9, 11, and 14) at risk for unrecognized clinical and psychological changes and had an incomplete record of the seclusion.

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The facility failed to ensure 1 patient (#7) representative was notified of an incident that involved the patient and had the potential to effect treatment and potential outcome. This failed practice denied patients and/or their representatives the ability to make informed choices about patients care and safety at the facility.


Findings:


During an interview on 10/12/22 at 11:12 AM the Chief Nursing Officer stated staff were supposed to call administrator on-call if there is a problem in the facility.


During an interview 10/13/22 at 12:42 PM, Patient #7's Representative stated there had been bullying on the unit, he/she stated Patient #7 had told him/her [he/she] had been assaulted. The Patient Representative stated he/she was not notified. The Patient Representative stated there were inappropriate sexual comments between patients on the unit and patients were often near each other unsupervised, or in the dame room. Patient #7's Representative stated the Patient had to go to the emergency department because of a concussion from a fight.


Review of Patient #7's clinical record on 10/13/22 revealed a "Psychiatric Progress Note, dated 10/03/22, "Sexual conversation of a sexual nature [with] [boy/girl] on unit. The child was groped 2 weeks ago and the [family representative] did not find out until the family session. The therapist told me this did apparently happen."


Review on 10/13/22 of a "Clinical Therapy Progress Note", dated 10/04/22, "Pt let CT [clinical therapist] know a peer touched [his/her] [chest area] + it made [him/her] uncomfortable. CT will tell the nurse + the doctor."


During a telephone interview on 10/13/22 at 2:30 PM, Licensed Nurse (LN) #7 stated he/she did not recall the therapist mentioning Patient #7 making an allegation of being touched inappropriately on that date.


Review of the nurses' notes dated 10/03/22 and 10/04/22 revealed no information about Patient #7's allegation.


Review on 10/13/22, of the facility policy and procedure "Responding to Reports of Sexual Contact or Rape", reviewed 1/22, revealed:
"I. If a patient/resident alleges to have been subjected to unwanted sexual contact with another patient/resident at a North Star Behavioral Health System facility, the following procedure will be followed:
a. The patient/resident and the alleged perpetrator will be placed in separate areas and
provided with continuous monitoring and support.
b. The following people are to be notified:
i. Administrator or Administrator on Call
ii. Treating or On Call Physician
iii. Chief of Nursing, Director of Nursing or Clinical Director 1v. Risk Manager
iv. Risk Manager
v. Guardian(s) -Please Note: Notification will be done by the Physician or his/her designee such as the Administrator or Clinical Director.
viii. Office for Children's Services - Intake Department. Notification will be done by one of the following: Patient Advocate, Nursing Supervisor/CNO, DON, RTC Administrator or Clinical Director. For guidance with this, please review P&P RI 112 - Abuse Reporting.
viii. Anchorage Police Department
viii. For RTC: DBH Child Care Facility Licensing Representative and Disability Law

c. Both the alleged victim patient/resident and perpetrator be assessed and reassessed as
needed by the nurse.
d. Both the alleged victim patient/resident and perpetrator will receive a mental exam by the physician.
e. If ordered by the physician, staff will escort the victim patient/resident to Alaska Regional Hospital. In the case of an adult, the patient/resident will be taken to the hospital of
his/her choice. Once there staff/ patient/resident will request the Sexual Assault Response Team to provide a medical rape exam and counseling.
f. Lab testing for the following will be requested by the physician (as appropriate) ..."
"g. should a police report need to be filed, the Administrator or designee will provide assistance and support in this process.
h. The Patient Advocate is also informed of the event and provided with pertinent information.
2. The Risk Manager is responsible for:
a. Coordinating interactions with the police
b. Conducting an internal investigation of the allegation, and
c. Ensuring that all required notification is made.
3. As part of the coordinated investigation, evidence will be secured by the Risk Manager
including but not limited to:
a. Written Statements by staff and any witnesses
b. Surveillance/Security Tape
c. Copies of any external reports
d. Medical Records
e. Securing the area where alleged assault occurred.
4. Staff are responsible for completing all applicable documentation per protocol for any report of sexual assault that occurred during an admission at NSBHS.
5. At no time will any NSBHS staff member release portions of the medical record or items secured by the Risk Manager without approval from the Risk Manager or UHS Corporate Risk
Management Representative."

During an interview on 10/13/22 at 12:11 PM, the Chief Executive Officer (CEO) and the Director of Nursing Services stated the facility was rolling out a method to increase staff awareness of precursors of an abusive environment. The CEO stated they had been doing passive education by putting posters in the elevator.
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Based on record review, video review, observations, and interviews the facility failed to ensure adequate one to one monitoring (1:1-one staff assigned to one patient with direct supervision) to ensure a safe environment for 4 patients reviewed (#s 2, 3, 5 and 16), with an identified risk of assaultive and/or violent behaviors against and/or towards others, suicidal and/or self-harming behaviors, and failed to prevent access to objects that patients could use to harm themselves and/or others. These failed practices place patients at risk for harm from self and/or others due to lack of supervision.

Findings:

Monitoring

Patient #2

Record review on 10/7/22 of Patient #2 revealed diagnoses that included autism (a neurodevelopmental disorder characterized by impaired social interaction, verbal and non-verbal communication, and restricted and repetitive behavior), oppositional defiant disorder (a behavior condition, displaying patterns of uncooperative, defiant and angry behavior toward authority), and reactive attachment disorder (condition in which an infant or young child doesn't establish healthy attachments with parents or caregivers).

Review on 10/7/22 of the precautions listed on the "Monitoring Precautions Record and Sleep Log" for Patient #2, dated 10/1/22, were "SXP-A" (sexual precaution-aggression) Level 1; "HI" (homicide precaution); "Assaultive" precaution; "ELP" (elope precaution); patient in private room. Level of monitoring / Frequency of Observation: 1:1 while awake (per policy the patient/resident should be within close proximity and within the same room of assigned staff at all times), and every 15-minute visuals.


Patient #3

Record review on 10/7/22 of Patient #3 revealed diagnoses that included depression, oppositional defiant disorder, and attention deficit hyperactivity disorder. Precautions listed on the "Monitoring Precautions Record and Sleep Log" dated 10/1/22 were "SXP-A", "SPA-V" (sexual precaution-victim), "HI", "Assaultive" precaution, and "ELP". Level of monitoring /Frequency of Observation: 15-minute visuals.


A review of video footage, no audio available, was conducted on 10/11/22 with the Director of Quality Improvement/Risk Management (QIRM). The footage reviewed was 10/2/22 8:34 PM to 10/3/22 8:00 AM). The QIRM confirmed the census on 10/1/22 was 16 patients.

The video review revealed periods of time when 1:1 staff monitoring was not occurring with Patient #2. The following was observed during the video review:

8:34 PM Patient #2 kicked open the door of the comfort room and entered. Exited at 8:37 PM and walked to the nurse's station. No MHS staff are seen with the Patient.

8:47 PM Patient #2 entered another patient's room, exited room at 8:51 PM, walked to the nurse's station. Remained at nurse's station area until 9:13 PM. No MHS staff were seen with Patient #2.

8:59 PM MHS #8 was seen sweeping the hallway floor, mid-way from the nurse's station to the back door, MHS #9 standing mid-hallway and appeared to be speaking with MHS #8.

8:47-9:13 PM Patient #2 was without 1:1 monitoring for 26 minutes.

9:13 PM Patient #2 walked from the nurse's window to his/her room and returned to the nurse's window 9:14 PM. Seen playing with Rubik cube and then sitting on mattress by nurse's station.

9:25 PM MHS #8, the assigned 1:1 staff, is seen sitting on the floor, leaning against the wall near the comfort room at front of hall. Patient #2 remained near nurse's station.

9:29 PM Patient #3 observed standing near his/her room door, mid-hallway.

9:30 PM Patient #2 was sitting on floor near nurses' station.

9:34 PM MHS #8 remained seated on floor, near comfort room at front of hallway. Patient #3 observed talking with MHS #8.

9:38 PM MHS #9 standing near nurse's station, holding clipboard

9:39 PM - 9:43 PM Patient #2 continued playing with Rubik cube. MHS #8 continued sitting on floor, MHS #9 seated in chair, outside nurse's station, facing toward back of hallway.

9:44 PM - 9:48 PM Patient #2 is standing at nurses' station, Patient #3 was observed talking with MHS #8, then walked to mid-hallway and appeared to enter his/her room. (The patient rooms were located in a recessed alcove with 2 rooms per alcove. The room doors were located within the alcove were not well visualized from the camera located at the ends of the hallway.)

9:50 PM Patient #2 walked away from the nurse's station to mid-hallway, alcove of his/her room, located next to Patient #3's room, and appeared to enter a room.

9:50 PM - 10:11 PM MHS #8 and #9 remain at front of hallway, neither staff are within line of site of Patient #2, located mid-hallway. 10:11 PM MHS #8 seen walking to a room near back of hallway, appearing to perform the 15-minute checks on the patients.

From 9:50-10:13 PM, 23 minutes, Pt #2 is without 1:1 monitoring or 15-minute visual check.

10:13 PM MHS #8 was observed standing mid-hallway, in the alcove outside of Patient #2 and Patient #3's room.

During the video review, the QIRM stated "when staff opened the door, [Patient #3] started yelling 'don't open the door, I'm in the bathroom'."
Further video review revealed, MHS #8 opened a room door and appeared to talk with someone in the room.
The QIRM stated that both patients had been in Patient #3's room, unmonitored.

10:14 PM Patient #2 walked alone to the nurse's station.

10:16 PM Patient #3 observed standing in alcove to the rooms, talking with other patients who came out of their rooms from across the hallway.

10:20 PM Patient #2 observed speaking with MHS #8 in hallway, then walked back to nurse's station.

10:21 PM - 10:30PM Patient #2 remained at nurses' station, horsing around with other patients, who were nearby. No MHS staff are seen in the area with Patient #2 providing 1:1 monitoring. MHS #8 and MHS #9 both observed standing mid-hallway.

10:30 PM Patient #3 observed entering his/her own room.

10:38 PM MHS #10 observed walking onto the hallway of the unit.

10:45 PM MHS #s 8, 9, and 10 continued standing in hallway, midway from nurse's station to back of the hallway. Patient #3 was standing in the alcove by his/her room.

10:49 PM Patient #2 observed walking from the nurses' desk to his/her room.

10:51 PM Patient #3 walked to the nurse's station and remained until 11:05 PM then returned to his/her room. MHS #9 and #10 standing mid-hallway outside Patient #s 2 and 3's rooms.

11:14 PM Patient #2 exited his/her room, appears to speak to MHS #10, re-entered his/her room at 11:15 PM

11:18 PM Patient #2 walked to the nurse's desk alone.

11:27 PM Licensed Nurse (LN) #11 observed walking to Patient #2's room and pulled a mattress to the hallway.

11:30 PM Patient #2 laid down on the mattress

11:27 PM - 11:34 PM, no MHS staff are seen in hallway or near Patient #2

11:34 PM next shift staff can be seen walking onto the unit.

MHS #6 begins rounding on the unit and checking each room. Patient #2 continued to lay on the mattress in hallway

11:38 PM MHS #6 moved a chair to hallway, in front of alcove next to Patient #2's mattress.

11:43 PM Patient #2 got up from the mattress and walked to the nurses' station, MHS #6 followed Patient #2 and stood next to him/her.

Continued video review from 11:43 PM on 10/2/22 to 8:00 AM on 10/3/22 revealed Patient #2 slept on mattress in hallway, in line of sight from MHS staff. Review ended.

Further review of Patient #'2s medical record on 10/11/22 of the "Monitoring Precautions Record and Sleep Log", a form used to document every 15-minute visuals, revealed all entries on 10/02/22 from 8:30 PM to 11:15 PM documented a number 2 (lying or sitting) for behavior, and an H (hallway) for location. The documentation did not align with the observations of the video review.

Record review on 10/11/22 of the "MHS Intervention/ Progress Sheet", dated 10/02/22, revealed no documentation for "Evening Shift -Community, Treatment" sections. The right side of the form was blank.

Review on 10/11/22 of the MHS "Evening" progress note revealed two written entries by MHS #8: "Behavior: "Pt [Patient #2] was not follow direction" and "Pt not participated", "Intervention: monitoring" "Response/Plan: redirection"

Record review on 10/11/22 of the "Q [every] 1 Hour Notes for Staffing, 1:1 Staffing" revealed entries each hour from 4:00 PM to 7:00 PM stating "Pt [Patient #2] in the hallway"
Entry at 8:00 PM read "Pt in the hallway, pt. not follow direction"
Entry at 9:00 PM read "Pt in the hallway, no on the bed"
Entry at 10:00 PM read "Pt". No other documentation followed this.
No documentation for 11:00 PM
Shift Summary read "Pt was follow direction from staff." "Pt eloped from the unit to [another unit] unit"

Record Review on 10/11/22 of a "Nurses Daily Assessment/Progress Note" dated 10/2/22 for 7:00 PM - 7:00 AM shift revealed a nursing narrative by LN #11. Documentation reveals "Staff reportedly found [Patient #2] in the room with another pt. ...". The nurse's documentation further revealed that both patients made accusations of alleged assaults against each other. "On call MD was notified. Incoming RN [registered nurse] will notify parents and main physician ...Pt monitored one to one while awake, q15 [every 15 minutes] while asleep for safety and location. Continue to monitor"

During a telephone interview with LN #11 on 10/13/22 at 4:30 PM, when asked about the alleged assault incident on 10/2/22, LN #11 stated it "was unclear, confusing", "both Patients had come up to the desk at different times accusing each other". When asked what the MHS staff had reported to the nurse, the LN stated they had not notified nursing of anything at the time it had occurred", LN #11 was made aware of the incident when the patients had talked to him/her about the event. LN #11 stated that it was toward the end of shift when LN was made aware of any alleged incident. LN #11 stated he/she notified the on-call physician and gave report to the oncoming LN to make further notifications to parents, facility leadership and possible law enforcement.

During an interview on 10/12/22 with Psychiatrist #2, the on-call "long call" physician for 10/2/22, when asked if he/she had been notified of an alleged patient to patient assault incident on 10/2/22, he/she reviewed their laptop schedule and notes from that dated and stated "no, I was not called and I do not recall ever getting that information", when asked if staff should have notified him/her of the event, he/she stated "Yes, that is the expectation".

During an interview on 10/13/22 with Psychiatrist #6, the "short call" physician on 10/2/22, when asked if he/she had ever been notified of an alleged assault incident on 10/2/22, he/she replied "No, I was not". He/she stated the "short-call" was only on call until 6:00 PM and the long-call doctor would then be notified.


Patient #5

Observation on 10/7/22 at 8:30 AM on an adolescent unit revealed one patient, Patient #5, currently on a 1:1 monitoring status. MHS #7 was conducting the 1:1 monitoring for Patient #5 while another MHS staff member was on a break. MHS #7 was observed letting patients into the seclusion room area to use the restroom. MHS #7 stood by the locked door, holding it open while patients went in to use the restroom. Patient #5 was in the hallway, and walked in and out of the day room, not in direct site of MHS #7. When asked if he/she was doing 1:1 monitoring for Patient #5 and the 15-minute visuals for other patients, MHS #7 stated "yes" and showed the surveyor a clipboard with the 1:1 form for Patient #5 and all the 15-minute log forms for all the other patients on the unit.

Review of Patient #5's clinical record on 10/7/22 revealed the Patient had diagnoses that included depression and intermittent explosive disorder (repeated, sudden episodes of impulsive, aggressive, violent behavior or angry verbal outbursts in which you react grossly out of proportion to the situation) Further review revealed Patient #5 was to be on 1:1 monitoring while awake.

Review of a Psychiatric Note, dated 10/3/22, revealed Patient #5 was to remain on precautions for suicide, self-harm, elopement, and assault.

Further observations on 10/10/22 at 7:45 - 7:55 AM of an adolescent unit revealed MHS #7 standing in the hallway. When asked about what training he/she had received regarding 1:1 monitoring, MHS #7 stated he/she had been at the facility for "about 2 months", training was done through "HealthStream [web-based learning management platform]" on the computer. MHS #7 stated "I haven't completed all the training yet, hard to do when at work, no time built in for computer time". When asked about 1:1 training, MHS #7 stated "I think there is a section on HealthStream, I haven't completed it yet". When asked what his/her tasks on the unit were, MHS #7 stated "I don't know why I was sent over [from another unit], waiting for someone to tell me".

Continued observations on an adolescent unit on 10/10/22 from 8:00 - 8:07 AM, Patient #5 was observed standing in the day room, then running down the hallway to his/her room near the back of the hallway, entering his/her room and closing the door. No MHS staff was with Patient #5 or in line of site of the Patient.

During the observation at 8:07 AM the Assistant Administrator handed MHS #7 a clipboard and stated this was for the "new 1:1 assignment process". MHS #7 took the clipboard and began conducting 1:1 monitoring of Patient #5 as he/she came out of the room.

At 8:23 AM an observation was made at Patient #5 room door. Patient #5 was in his/her room with the door closed. Water could be heard running from the other side of the door. MHS #7 stood outside the room, next to the closed door and holding the clipboard. When asked if he/she was conducting 1:1 monitoring for Patient #5, he/she stated "Yes", when asked how he/she could conduct 1:1 monitoring with a door closed, MHS #7 stated "patient was a 1:1 due to bullying by other patients", and further stated "yesterday some things were changed with binders and clipboards for 1:1's". MHS #7 showed the clipboard with some instructions on the back and stated, "there is some confusion on the level of monitoring, I need to get clarification". MHS #7 further stated, regarding 1:1 monitoring, "sometimes with staffing, it's difficult."


Patient # 16

During a phone call on 10/13/22 at 9:39 AM LN #3 stated he/she was working at the hospital on 9/03/22 when Patient #16 eloped from the floor and attempted to harm him/herself in the stairwell. The LN stated the Patient, who was supposed to be on 1:1, became upset after a zoom therapy session, had jumped on the elevator, ran downstairs through the cafeteria, and hid in the stairwell. Patient #16 dug a drywall nail (screw) out of the wall and used it to cut a strip of cloth off his/her pants and wrapped it around his/her neck. The LN stated staff had to cut the pants from around Patient #16's neck, the Patient then swallowed the nail. Patient #16 was then sent to the hospital for evaluation of the ingestion of a foreign body.


Review of Patient #16's clinical record on 10/10-13/22 revealed a "Psychiatric Progress Note", dated 9/02/22 "The Patient had a diagnosis of major depression ...says [he/she] has suicidal thoughts ...[He/she] is already on 1:1 for [his/her] suicidal thoughts."
"Plan: 1. Continue one-to-one for safety."


Review of Patient #16's clinical medical record on 10/12-13/22 revealed "Final Ancillary Orders (non-med)",
"1:1 Observation while awake"
"Start time 8/31/22 17:00 Stop Time 9/7/22 17:35"
"1:1 UR [unit restriction] Observation"
"Start Time: 8/31/22 17:00 Stop Time: 9/07/22 17:35"


During an interview on 10/13/22 at 1:40 PM, LN #9 reviewed the medical record and stated Patient #16 had orders for 1:1 on 9/03/22.


During an interview on 10/13/22 on 3:30 PM, when asked about Patient #16 being on 1:1 and if he/she was on 1:1 at the time the elopement and attempted strangulation happened, Psychiatrist #1 stated he/she would have to look at his/her notes, but he/she did not think the Patient was on 1:1 observation the time. The Psychiatrist stated Patient #16 would do things for attention and liked having the 1:1. Psychiatrist #1 stated it was difficult having patients on 1:1 because the patients would have to stay on unit restriction. He/she stated Patient #16 had since been discharged to a treatment facility.

During the interview, the Psychiatrist stated the hospital unit at the other building had been closed as patients had been pulling the carpet apart and attempting to choke themselves with the threads.


During a returned phone call on 10/13/22 at 5:23 PM Mental Health Staff (MHS) #11 stated he/she was working on the unit Patient #16 resided on when he/she eloped from the unit. The MHS stated there was one other MHS and a nurse working. He/she stated staff from the Chris Kyle/ Artic Recovery units (part of the hospital in a separate building), was supposed to come over to assist, but he/she had not seen them. MHS #11 stated Patient #16 often engaged in self-harm and was supposed to be on a 1:1 observation. The MHS stated they did not have the staff to cover the other patients on the floor and provide the 1:1 monitoring to Patient #16 effectively.


The MHS stated Patient #16 sometimes came off and on the 1:1 status, which was confusing because the Patient would always try to harm him/herself. The MHS stated that day LN #4 had called trying to find extra staff to help. The MHS stated on 9/03/22 Patient #16 had been alone in the family visiting room (located outside of the locked unit and next to both elevators), participating in a zoom call with his/her doctor. MHS #11 stated LN #4 had taken patients downstairs while he/she remained on the locked unit with the other patients. The MHS stated after the zoom call ended Patient #16 came bursting out of the door stating, "I'm done with this" and jumped on an elevator and left the floor. The Patient then accessed a stairwell and tried to strangle him/herself. He/she later was sent to the hospital because he/she had swallowed a nail (screw).


Further review of Patient #16's clinical record on 10/12-13/22, revealed a "Nurses Daily Assessment/Progress Note", dated 9/03/22, "Suicidal-1", "Assulative-2', "Elopment-2", "SXPV-1", "Self-Harm-1', 'Q [every] 15- min checks" were marked. " ...is still on 1:1 WA [while awake]. After seeing the MD by zoom [he/she] stormed out. [he/she] went up to the 3rd floor stair and stairs [started] to bang the wall, [he/she] ripped [his/her] pants and wrapped it around [his/her] neck. [He/she] was processed and intervention was called. [he/she] gave up the contrabands and RN reported that [he/she] swallowed a screw. [he/she] was sent to the ER to have [him/her] assessed ...Staff will continue to monitor for Q 15 minutes for comfort, safety, and location."


Review of the "Hospital Monitoring Precautions Record and Sleep Log", dated 9/3/22, revealed the "Level of Monitoring/Frequency of Observations:" was marked as "Q15 min visuals". The place for "RN supervision initials and time" had been left blank."

Review of a "MHS Intervention/Progress Note", 9/03/22, revealed "Observation Level" 1:1 while awake" "15 min checks" "SXP [Suicide Precautions]" and "SH [Self Harm] were marked as a level 1. On the back "Day Progress Notes: Behavior: "During lunch time Pt. [Patient #5] talked to the doctor. Pt. got upset after meeting and walked off unit. Pt. sat in stairs and did not follow directions. Pt. was monitored. Pt. self-harmed and got sent to get treatment."


Review of a 9/03/22 "Evening Progress Note: behavior: Pt. was hospitalized most of shift-returned back to unit around 2 pm [and] ate dinner-in better mood but still showing signs of depression."
"Intervention (Specify reinforcer used during shift): Q 15's"


Review of a "Nurses Daily Assessment/Progress Note", for 7:00 PM-7:00 PM "Night Shift" dated 9/03/33 at 7:00 AM Shift revealed. "Precautions:" were marked for "Suicidal:1", "Elopment:1" "SXPV-1", "Self-Harm-1" "1:1 Status WA" "Q 15 min checks". "Nurse Notes ...In system consult ordered for patient, they had consumed a glove and two cheese stick wrappers."


Review of a "Nurses Daily Assessment/Progress Note", dated 9/04/22 from 7:00 AM-7:00 PM "Day Shift" revealed. "Precautions:" were marked for "Suicidal:1", "Elopment:1" "SXPV-1", "Self-Harm-1" "Q 15 min checks".


Review of the "Nurses Note" revealed " ... [he/she] is still on 1:1 WA. This morning [he/she] had [his/her] [undergarment] wrapped very tightly around [his/her] neck. The [undergarment] was cut off but left petechia [pinpoint bleeds] on [his/her] face. MD notified. No new orders received ...Staff will continue to monitor 1:1 WA for comfort, safety, and location."


Review of the facility policy on 10/13/22 "Special Precautions and Levels of Monitoring, motion sensors PCl46", revised 2/22, revealed "It is the policy of North Star Behavioral Health System (NSBHS) to establish and maintain an environment that optimizes safety for patients/residents, staff, and visitors through ongoing assessment of and close monitoring for risk of harm and the implementation and maintenance of prevention and intervention strategies that effectively eliminate high risk opportunities and/or ameliorate high risk situations."

"Procedures"
I.A comprehensive evaluation for the following will be performed and documented on all individuals assessed by the Intake staff at North Star Hospital for the following:
-current risk to self/others;
-history of suicidal/homicidal/assaultive ideation/behaviors;
-accuracy of reports and history of risk;
-suicide/homicide/assaultive risk factors.
-Risk to act out sexually.
-Risk to elope from NSBHS"

"III. If risk of harm to self or others is present at the hospital admission or anytime during the stay, the admitting or attending physician will order monitoring consistent with the level of risk identified. North Star facilities utilizes the following safety precautions:
-Suicide Precautions
-Homicide Precautions
-Assault Precautions
-Sexual Precautions
-Elopement Precautions
-Seizure/Fall Precautions
-Self-Harm Precautions
-Safety Precautions (RTC only)

In the NS [North Star] acute facilities, precautions are on a level system:
I.Level I indicates any degree of risk as evidenced by recent and/or current active behaviors/verbalization of risk.
2. Level II indicates a low risk based on a history of unsafe behaviors/thoughts absent of recent and/or current risk-related behaviors/verbalizations.
3. All precautions ordered at the time of a North Star acute admission shall be at level
one and remain at said level until assessed in person by the attending psychiatrist."
IV.As part of the daily nursing progress note, nursing staff shall document the presence or absence of applicable behavior for which the precaution is ordered.
V.The Physician will specify reason for monitoring and choose the frequency of observation. Patients at all NSBH facilities are observed directly at a minimum of every 15 minutes. The Physician may choose to add an observation level of 1:1 (patient to be assigned a staff to directly supervise patient/resident), depending upon patient/resident severity.

Physician will specify if the 1:1 monitoring is to be:
-While awake only (15-minute visuals to be done when sleeping)
-24 hour
-Shift specific"

Further policy review revealed "The purpose of this policy is to establish procedures which support the following: 1. Optimize safety for patients/residents, staff, and visitors in an acute hospital/RTC setting 2. Ongoing assessment of and close monitoring for risk of harm 3. Implementation and maintenance of prevention and intervention strategies that effectively eliminate high risk opportunities and/or ameliorate high risk situations ...Further review of the policy and procedure revealed "1:1 Monitoring ...The patient/resident should be within close proximity and within the same room of assigned staff at all times.
Patients/residents who are on 1:1 monitoring are to be directly observed while completing dressing, toileting, and/or bathing activities ...
-Patients/residents on 1:1 observation levels are never to be left alone. Should a staff member need to leave, he/she is responsible for locating another staff member to take over observation of the patient/resident. The departing staff member is required to pass on all pertinent information regarding the patient to the arriving staff member. This "pass off' is to be done in person and allow the receiving staff the opportunity to ask questions regarding the patient/resident."


Elopement incident

A review of video footage was conducted on 10/11/22 at 12:29m with the Director of Quality Improvement/Risk Management (QIRM). The footage reviewed was from an elopement event on 10/2/22 at approximately 9:30pm on an Adolescent Unit.

-The review revealed several of the patients had been playing in the back of the hallway, farthest from the nurse's station.

-Two Mental Health Specialist's (MHS) were seen standing in the hallway near the front end close to the nurse's station.

-One patient started running and sliding on a mattress in the hallway (similar to a slip and slide), this was done several times

-Another patient was seen carrying a blue mattress into the hallway between the back door and the front, holding it upright and blocking the line of site with the staff, at this time, another patient was seen moving quickly to the back door and then followed by 5 other patients.

Further review of video footage from the cafeteria revealed 2 patients entering the cafeteria, finding a fire extinguisher, and walking toward a door. A patient could be seen swinging it at the door.

The footage revealed staff had entered the cafeteria area searching for the patients that had ran off the unit.
Further review of footage from the Gym area revealed the 4 other patients running through the gym to a door leading to the outside.

When asked what happens when patients elope from a unit, the QIRM stated a "code would be called alerting staff in the building of the event, and they would go to the exits". When asked how the unit door was opened by the patient, QIRM stated "an employee had resigned over the weekend and handed their keys to the nurse on the unit", "we are unsure of where the keys had been placed and think one of the [patients] were able to reach them."

During an interview on 10/12/22 at 11:30 AM with LN #10 when asked about the elopement event, LN #10 stated "we think they got a hold of a key, a staff member had quit, and the keys may have been left on the desk and not placed out of reach. LN #8, also stated that it was suspected the keys were reached by one of the patients.

Record review of MHS progress notes, for Pt #1, dated 10/1/22 reveal entry stating "tries to grab keys"

Interviews with MHS and LN staff confirm the patients are frequently attempting to grab their keys off the staff arms, "a usual occurrence, on all the units".

Record review of a Nursing Daily Assessment/Progress Note dated 10/2/22 7:00 AM, from the nurse on duty during the event revealed " ...patient and peer eloped off the unit and then out of the facility. Staff reported that patient and peer were seen to use badge and keys to elope ...", "patient and peer returned, no injuries reported ... ..."

Record review of a Nursing Daily Assessment/Progress Note dated 10/3/22 4:30 PM revealed " ...patient denies having a badge or keys in person despite being seen with the items during elopement ...."

Record review of a Clinical Therapy Progress Note dated 10/3/22, for session time of 1:00-1:30 pm, revealed " ...Pt was forthcoming and told CT [clinical therapist] that he knows who has the badge and keys. Pt brought CT the badge five minutes after the session and the keys about 15-30 minutes after. Pt state that the peer through [sp] the key because they didn't want to get caught with it ..."

Observation of the nurse's station on the second floor revealed the nurse's station is set between 2 units. Locking double doors are on each side of the desk that led to the individual units where patient reside. The nursing desk upper counter, on the elevator side, is approximately 42 inches high and open with accessibility (by reaching over) to the lower nurse's desk where staff work. There are plexi-glass type windows that slide open on each end of the desk, facing the locked units, that nurses use to talk with the patients and administer medications. Patients can reach through the window and easily access items within arm's reach. The sliding window has a locking mechanism that can be utilized.

Observation on 10/12/22 from the nurse's desk on the 2nd floor revealed a patient brought to the open side of the nurses' station, by a physician, to make a phone call. The phone was placed onto the upper desk by nursing staff. Items on the lower desk were within arm's reach of the patient.
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Based on video review, record review and interview. The facility failed obtain verbal orders that identified the type of seclusion and/or verbal restraint for 3 patients (#7, 9, and 11). These failures created a risk for patients being placed in restraints and/or seclusion without a physician determining the appropriateness for each restraint episode. Findings:


Patient #7

A video review, conducted with QIRM (Quality Improvement/ Risk Manager) on 10/10/22 at 2:30 PM, revealed Mental Health Staff (MHS) #2 physically forced Patient #7 into the seclusion room on 10/02/22.

Review of Patient #7's medical record on 10/10-13/22 revealed Patient #7, a minor, had a diagnosis that included post-traumatic stress disorder, was placed in seclusion on 10/02/22 at 3:05 PM.
Review of the restraint and seclusion orders dated 10/02/22, revealed the verbal order was for seclusion, not a restraint.


Patient #9

Review on 10/11-12/22 of Patient #9's record, a minor with diagnosis that included post-traumatic stress disorder, was placed in seclusion on 10/2/22 at 9:25 AM.

The physician's verbal order did not indicate the type of intervention ordered by the physician (restraint and/or seclusion).



Patient #11


Review on 10/11-12/22 of Patient #11's record, a minor with diagnosis that included post-traumatic stress disorder, was placed in seclusion on 10/2/22 at 3:05 PM.

The verbal physician's order,10/2/22, did not indicate the type of intervention (restraint and/or seclusion) ordered by the physician.

During an interview on 10/13/22 at 12:11 PM, when asked how they provided support to staff who had not completed the seclusion training, the Director of Nursing Services stated a Nurse Manager had been helping with the paperwork.

Review on 10/13/22 of the facility policy and procedure titled "Proper use and monitoring of Physical/Chemical Restraints and Seclusion - Acute", revised 4/22, revealed "The physician's order for use of restraint or seclusion will be recorded in the medical record and include the following ...The type of restraint or seclusion to be used."

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Based on record review, video review, and interview the facility failed to ensure unlicensed staff (mental health specialists) had been provided training to implement components of seclusion delegated by registered nursing staff for 4 patients (#s7, 8, 9, and 11) in seclusion. This failed practice placed patients at risk for an ineffective assessment of seclusion interventions and a failure to recognize psychological and/or physical harm.
Findings:

Patient #7
Record review on 10/10-13/22 revealed Patient #7, a minor, with a diagnosis that included post-traumatic stress disorder, was placed in seclusion on 10/02/22 at 3:05 PM.

Intervention ..." was marked "Imminent Danger to Others" "Describe specific behaviors" Assaultive Behaviors to Staff."

A video review, conducted with QIRM (Quality Improvement/ Risk Manager) on 10/10/22 at 1:40 PM, revealed Mental Health Specialist (MHS) #2 physically forced Patient #7 into a seclusion room on 10/02/22. Continued video review revealed MHS #2 in the anteroom (a small outer room that leads to all 4 seclusion room) observing the other 3 seclusion rooms.


Video review of Patient #7 in the seclusion room revealed the Patient visibly calling out and hitting the door and pulling on the door handle. There was no sound and the entire room was not in frame.


During the review it was noted the other seclusion rooms had Patients, identified as Patient #s 8 and 9.


Video review of Patient #8, in another seclusion room, revealed patient standing in the room visibly crying (face scrunched up, frowning, and shoulder shaking).


Video review of Patient #9 revealed the Patient was sitting on the floor of another seclusion room.

Patient #11, who was also in seclusion was not observed on camera.


During the video review, MHS #2 was observed, looking in the windows by turn at the children, leaving the anteroom, returning, and then assisting Licensed Nurse #2 with giving hydration to the patients in the rooms. Occasionally MHS #12 was observed in the anteroom assisting.


Record review on 10/10-13/22 of Patient #7, 8, 9, and 11's medical records revealed on 10/02/22, the "Seclusion/Restraint Monitoring" logs, where the monitored patient responses to the seclusion were to be documented, were not filled out.


Review of a sample list of clinical staff provided to the facility, on 10/12/22, revealed 3 mental health specialists (MHS), including MHS #2 had not completed seclusion training.


During an interview on 10/12/22 at 11:17 AM, the Director of Human Resources (DHR) stated not all the employees on the nursing units had completed training for seclusion. She stated that they may have received in-person training on the floor. The DHR stated the facility planned to schedule a time for the employees to complete this.

During an interview on 10/12/22 at 12:00 PM, MHS #2 stated he/she was working on 10/2/22 and assisted with restraining and secluding the children that day. The MHS stated he/she had completed the training on "Handle with Care", a training used for safely managing challenging and disruptive behavior that also teaches physical holds. The MHS stated he/she how to implement seclusion had not been included in the training. When asked how often patients were to be monitored when they were in seclusion, the MHS stated someone told him/her they need to be check on every 5 minutes and someone else stated every 15 minutes. MHS #2 stated he/she tries to check on the patients every 5 minutes. The MHS stated he/she had recently started working at the facility.

Review on 10/12-13/22 of the facility policy "Proper use and monitoring of Physical/Chemical Restraints and Seclusion - Acute", revised 4/22 revealed:
13.0 Documentation of use of restraint/seclusion: The use of restraint/ seclusion will be thoroughly documented in the patient's medical record. Documentation related to restraint/seclusion includes:
13.1 That the patient and/or family were informed of the hospital's policy on the use of
restraint/seclusion and consent for notification.
13 .2 The initial assessment of the patient related to restraint/seclusion use.
13.3 Documentation of each episode of restraint/seclusion includes:

The circumstances that led to the use of restraint/ seclusion
13 .3. I. I Specific behaviors
13.3. 1.2 Detailed description of events leading up the incident and other pertinent information
Consideration or failure of non-physical interventions
The rationale for use of restraint/seclusion
Notification of the patient's family when appropriate
Written orders for use-including each order for continuation
Behavioral criteria for discontinuation of restraint/seclusion
Informing the patient of behavioral criteria for discontinuation of restraint/seclusion
Check of appropriate restraint application
The initial in-person and subsequent evaluations of the patient
15-minute assessments of the patient's status."

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The facility failed to ensure staff conducting the 1-hour face to face assessment following seclusion implemented for 5 patients (#s 7, 8, 9, 11, and 14) was not performed by a Qualified Registered Nurse that had been trained and demonstrated competencies in the facility's seclusion policies. This failed practice placed psychiatric patients at risk for unrecognized trauma and/ or harm and potential subsequent disruption to therapy from the use of seclusion.

Findings:

Employee record review on 10/12/22 revealed Licensed Nurse (LN) #2 had not completed seclusion training which included the face-to-face training.
Record review on 10/10-12/22 revealed LN #2 had placed 5 patients in seclusion throughout the identified time frame. There was no evidence in the medical record another nurse assisted with the face-to-face or the provider was onsite to assist with the assessment.

Patient #7

Record review on 10/10-13/22 revealed Patient #7, a minor, with a diagnosis that included post-traumatic stress disorder, was placed in seclusion on 10/02/22 at 3:05 PM.
Intervention ..." was marked "Imminent Danger to Others" "Describe specific behaviors" Assaultive Behaviors to Staff."


Patient #8
Review on 10/11-12/22 of Patient #8's record revealed patient was a minor, with diagnosis that included attention deficit hyperactivity disorder, was placed in seclusion on 10/2/22 for 40 minutes.

Record review on 10/10-12/22 revealed Patient #8 was placed in seclusion on 10/02/22 at 3:05 PM. The "Reason for Intervention ..." was marked "Imminent Danger to Others" "Describe specific behaviors: Pt was severely agitated."

Patient #9

Review on 10/11-12/22 of Patient #9's record revealed patient was a minor, with diagnosis that included post-traumatic stress disorder, was placed in seclusion on 10/2/22 for 55 minutes.


Record review on 10/10-12/22 revealed Patient #9 was placed in seclusion on 10/02/22 at 3:05 PM. The "Reason for Intervention ..." was marked "Imminent Danger to Others" "Describe specific behaviors: Assaultive Behavior to Staff, Property Damage."


Patient #11

Review on 10/11-12/22 of Patient #11's record revealed patient was a minor, with diagnosis that included post-traumatic stress disorder, was placed in seclusion on 10/2/22 at 3:05 PM.

Record review on 10/10-12/22 revealed Patient #11 was placed in seclusion on 10/02/22 at 3:05 PM. The "Reason for Intervention ..." was marked "Imminent Danger to Others" "Describe specific behaviors: Assaultive Behavior to Staff."


Patient #14

Review on 10/11-12/22 of Patient #14's record revealed patient was a minor, with diagnosis that included depression post-traumatic stress disorder, was placed in seclusion on 10/2/22 at 9:28 AM.

The "Reason for Intervention ..." was marked "Imminent Danger to Others" "Describe specific behaviors: Assaultive to peers and staff."

Further review on 10/11-12/22 of Patient #14 record revealed he/she was placed in physical restraint and seclusion on 10/2/22 at 11:15 AM.

The "Reason for Intervention ..." was marked "Imminent Danger to Others" "Describe specific behaviors: Clients fighting on floor upset about separation."

Review on 10/23/22 of the 1-hour face-to face conducted on the 5 patients on 10/02/22 revealed LN #2 had completed the reviews and a physician had not reviewed the patients for the 1 hour face-to-face.

During an interview on 10/13/22 at 12:11 PM, when asked how they provided support to staff that had not competed the seclusion training, the Director of Nursing Services stated a Nurse Manager had been helping with the paperwork.


Review on 10/13/22 of the facility policy titled "Proper use and monitoring of Physical/Chemical Restraints and Seclusion - Acute", revised 4/22, revealed:
"Face to Face Evaluation by the Physician, LIP, or trained RN/PA: Within one hour of the initiation of restraint or seclusion, the patient shall be evaluated in person by a physician, authorized LIP, or trained RN/PA. A telephone call or telemedicine methodology is not allowed for these evaluations. The evaluation will be documented in the medical record to include the following:
The date and time of the evaluation
An assessment of the patient's immediate situation
An evaluation of the patient's reaction to the intervention
An assessment of the patient's medical and behavioral condition, to include a complete review of systems assessment, behavioral assessment as well as a review and assessment of the patient's history, drugs and medications, most recent lab work, etc.
An assessment of the need to continue or terminate the restraint/seclusion. At the time of the in-person evaluation, the individual conducting the evaluation works with the patient and staff to identify ways to help the patient regain control, make necessary revisions to the patient's treatment plan, and if necessary, provide a new order.
If the evaluation is conducted by a trained RN or PA, he/she must consult with the attending physician or other LIP responsible for the patient's care as soon as possible (within 30 minutes) after the evaluation. This consultation should include a discussion of the findings of the I-hour evaluation, the need for other interventions or treatments, and the need continue or discontinue the use of restraint/seclusion. The consultation must always be conducted prior to a renewal of the order."

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Based on record review and interview the facility failed to ensure the on-call physician, and/or other independent practitioner was notified of the results of the face-to-face assessment. This failed practice placed 5 patients (#7, 8, 9, 11, and 14) at risk for not having a physician review any findings from the face-to-face assessment.
Findings:

Employee record review on 10/12/22 revealed Licensed Nurse (LN) #2 had not completed seclusion training for nurses and the Director of Nursing Services completed her education on 10/11/22.

Patient #7

Record review on 10/10-12/22 revealed Patient #7 was placed in seclusion on 10/02/22 at 3:05 PM. The "Reason for Intervention ..." was marked "Imminent Danger to Others" "Describe specific behaviors" Assaultive Behaviors to Staff."

Review of the "Post Intervention Face to Face Evaluation", dated 10/02/22, revealed "Based on system reviews behavioral assessment, recent lab review, medical history, medication regime, drug history, are there any factors contributing to the patient's violent self-destructive behavior?" Marked "Yes, describe [history] of assaultive behavior."

"Continued Need for restraint/seclusion:" marked "NA not applicable] ..."
"Guidelines provided to staff in identifying ways to help patient gain control" marked "No"
"Treatment Plan Modification Indicated:" marked "Yes"

The section below "MD Notification of Evaluation (If evaluation completed by an RN/PA) The patient's attending MD has been notified of this evaluation." was blank.


Patient #8
Review on 10/11-12/22 of Patient #8's record revealed patient was a minor, with diagnosis that included attention deficit hyperactivity disorder, was placed in seclusion on 10/2/22 for 40 minutes.

Record review on 10/10-12/22 revealed Patient #8 was placed in seclusion on 10/02/22 at 3:05 PM. The "Reason for Intervention ..." was marked "Imminent Danger to Others" "Describe specific behaviors: Pt was severely agitated, yelling, screaming, and tried to hit staff, placed in hold and seclusion for safety."

Review of the "Post Intervention Face to Face Evaluation", dated 10/02/22, revealed "Based on system reviews behavioral assessment, recent lab review, medical history, medication regime, drug history, are there any factors contributing to the patient's violent self-destructive behavior?" Marked "No"
"Continued Need for restraint/seclusion:" marked "NA not applicable] ..."
"Guidelines provided to staff in identifying ways to help patient gain control" marked "NA"
"Treatment Plan Modification Indicated:" marked "Yes"


"MD Notification of Evaluation (If evaluation completed by an RN/PA) The patient's attending MD has been notified of this evaluation" was not filled out with the MD's name and time of notification.


Patient #9

Review on 10/11-12/22 of Patient #9's record revealed patient was a minor, with diagnosis that included post-traumatic stress disorder, was placed in seclusion on 10/2/22 for 55 minutes.


Record review on 10/10-12/22 revealed Patient #9 was placed in seclusion on 10/02/22 at 9:29 AM and 3:05 PM. The "Reason for Intervention ..." was marked and filled in "Imminent Danger to Others" "Describe specific behaviors: Assaultive Behavior to Staff. Destruction of Property" and "Imminent Danger to Others" "Describe specific behaviors: Assaultive Behavior to Staff."

Review of the "Post Intervention Face to Face Evaluation", dated 10/02/22, revealed "Based on system reviews behavioral assessment, recent lab review, medical history, medication regime, drug history, are there any factors contributing to the patient's violent self-destructive behavior?" Marked "yes" "Hx of Assaultive Bx [behaviors]"
"Continued Need for restraint/seclusion:" marked "NA not applicable] ..."
"Guidelines provided to staff in identifying ways to help patient gain control" marked "NA"
"Treatment Plan Modification Indicated:" marked "Yes"


The section below "MD Notification of Evaluation (If evaluation completed by an RN/PA) The patient's attending MD has been notified of this evaluation" was not filled out with the MD's name and time of notification.


Patient #11

Review on 10/11-12/22 of Patient #11's record revealed patient was a minor, with diagnosis that included post-traumatic stress disorder, was placed in seclusion on 10/2/22 at 3:05 PM.

Record review on 10/10-12/22 revealed Patient #11 was placed in seclusion on 10/02/22 at 3:05 PM. The "Reason for Intervention ..." was marked "Imminent Danger to Others" "Describe specific behaviors: Assaultive Behavior to Staff."
Review of the "Post Intervention Face to Face Evaluation", dated 10/02/22, revealed "Based on system reviews behavioral assessment, recent lab review, medical history, medication regime, drug history, are there any factors contributing to the patient's violent self-destructive behavior?" Marked "yes" "Hx of Assaultive Bx"
"Continued Need for restraint/seclusion:" marked "NA not applicable] ..."
"Guidelines provided to staff in identifying ways to help patient gain control" marked "NA"
"Treatment Plan Modification Indicated:" marked "Yes"

The section below "MD Notification of Evaluation (If evaluation completed by an RN/PA) The patient's attending MD has been notified of this evaluation" was not filled out with the MD's name and time of notification.


Patient #14

Review on 10/11-12/22 of Patient #14's record revealed patient was a minor, with diagnosis that included depression post-traumatic stress disorder, was placed in seclusion on 10/2/22 at 9:28 AM.


The "Reason for Intervention ..." was marked "Imminent Danger to Others" "Describe specific behaviors: Assaultive to peers and staff."

Review of the "Post Intervention Face to Face Evaluation", dated 10/02/22, revealed "Based on system reviews behavioral assessment, recent lab review, medical history, medication regime, drug history, are there any factors contributing to the patient's violent self-destructive behavior?" Marked "yes" "Hx of Assaultive Behavior"
"Continued Need for restraint/seclusion:" marked "NA" ...Client calmed down on own"
"Guidelines provided to staff in identifying ways to help patient gain control" marked "Counseled client on ways to moderate behavior"
"Treatment Plan Modification Indicated:" marked "Yes"


The section below "MD Notification of Evaluation (If evaluation completed by an RN/PA) The patient's attending MD has been notified of this evaluation" was not filled out with the MD's name and time of notification.


During an interview on 10/10/22, when asked if he/she had received training from the facility on seclusion, LN #2 stated "from another hospital but not from North Star Hospital". The LN stated he/she usually worked over on adult treatment unit (Chris Kyle/Artic Recovery Hospital) building. LN #2 stated on 10/02/22 the patients had become upset when staff conducted a contraband search. The LN stated staff had found 2 screws on a patient and found 4 more screws in with the patients' belongings. The LN stated he/she tried to help out on the floor as much as possible, but it made it difficult to get his/her own work done (such as passing medications). On 10/02/22 he/she only had 2 MHS staff helping on the unit and one of the staff struggled as he/she didn't normally work that unit.


During an interview on 10/13/22 at 12:11 PM, when asked about untrained staff implementing seclusion, the Director of Nursing Services stated a Nurse Manager had been helping with the paperwork.


Review on 10/13/22 of the facility policy titled "Proper use and monitoring of Physical/Chemical Restraints and Seclusion - Acute", revised 4/22 revealed:
"If the evaluation is conducted by a trained RN or PA, he/she must consult with the attending physician or other LIP responsible for the patient's care as soon as possible (within 30 minutes) after the evaluation. This consultation should include a discussion of the findings of the I-hour evaluation, the need for other interventions or treatments, and the need continue or discontinue the use of restraint/seclusion. The consultation must always be conducted prior to a renewal of the order."
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Based on employee record review and interviews facility failed to ensure staff assigned to patient care responsibilities had completed competencies in the application, implementation, and monitoring of patient seclusion. This failed practice placed all patients in the hospital with potential histories of trauma, depression, and mental illness at risk for harm from injurious behavior and/or psychological harm.

Findings:

Review of a sample list of clinical staff provided to the facility, on 10/12/22, revealed 1 licensed nurse (LN) and 3 mental health specialists (MHS) had not completed their seclusion training; The Director of Nursing Services completed her training on 10/11/22.


During a telephone interview on 10/11/22 at 3:48 PM when asked if he/she had received training from the facility on seclusion LN #2 stated not from North Star Hospital, the LN stated he had received training "from another hospital". The LN stated he/she was working on 10/02/22 and on that date the children and become aggressive and assaultive with staff and several had to be manually restrained and placed in seclusion. LN #2 stated he/she usually worked on an as needed basis at the adult treatment unit (Chris Kyle/ Artic Recovery) building of the hospital.


During an interview with on 10/12/22 at 11:17 AM, the Director of Human Resources (DHR) stated not all of employees on the nursing units had not completed training for seclusion. She stated that they may have received in person training on the floor. DHR stated the facility planned to schedule a time for the employees to complete this.


During an interview on 10/12/22 at 12:00 PM, Mental Health Specialist (MHS) #2 stated he/she was working on 10/02/22 and assisted with restraining and secluding the children that day. The MHS stated he/she had completed the training on "Handle with Care", a training for manual holds. MHS stated he/she had not completed any seclusion training. When asked how often patients were to be monitored when they were in seclusion, the MHS stated someone told him/her they need to be check on every 5 minutes and someone else stated every 15 minutes. MHS #2 stated he/she tries to check on the patients every 5 minutes. The MHS stated he/she recently started working at the facility.


Review on 10/13/22 of the facility policy on 12/13/22, "Proper use and monitoring of Physical/Chemical Restraints and Seclusion - Acute", revised 4/22 revealed
"Medical staff, direct care staff, and RNs/PAs [registered nurses and physician assistants] are oriented to the standards for the use of restraint/seclusion. Direct care staff and PAs are required to attend a nationally recognized physical/aggression management training program and show evidence of competency related to participating in a code situation, application of restraints, or the monitoring, assessment, and care of a patient in restraints or seclusion. Physicians and other LIPs authorized to order restraint or seclusion must have a working knowledge of the facility's policy regarding the use of restraint/seclusion. Nurses and P As authorized to conduct the I-hour face-to-face evaluation will receive additional training and demonstrate competency to conduct both a physical and behavioral assessment of the patient. All records documenting completion of training and competency demonstration will be maintained in staff personnel files or credentials files.

As part of orientation, before performing any of the actions outlined in this policy, and at least annually, training occurs as outlined below.
14.1 Training requirements for all direct care staff, including contract or agency personnel (RNs, LPNS/LVNs, MHTs): In order to minimize the use of restraint/seclusion, all direct care staff, as well as any other staff involved in the use of restraint/seclusion receive on-going training and demonstrate an understanding of:
14.1.1 The underlying causes of threatening behaviors exhibited by individuals they serve including patient and staff behaviors, events, and environmental factors.
14.1.2 Individuals that may exhibit an aggressive behavior that is related to a medical condition and not to his/her emotional condition, for example, threatening behavior that may result from hypoglycemia or delirium in fevers;
14.1.3 Staff behaviors impact on the behaviors of patients;
14.1.4 Alternative techniques to redirect a patient, engage the patient in constructive discussion or activity, or otherwise help the patient maintain self-control and avert escalation. Techniques may include de-escalation, mediation, self-protection, and other non-physical techniques such as time outs."

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Based on record review and interview the facility failed to ensure clinical staff implementing seclusion were trained and had competency in monitoring psychiatric patients in seclusion. This failed practice placed 5 patients (#s7, 8, 9, 11, and 14) at risk for unrecognized clinical and psychological changes and had an incomplete record of the seclusion.

Findings:


Review of a sample list of clinical staff provided to the facility, on 10/12/22, revealed 1 licensed nurse (LN) and 3 mental health staff (MHS) had not completed their seclusion training; The Director of Nursing Services had competed her training on 10/11/22.

Patient #7

Review on 10/11-12/22 of Patient #7's record revealed patient was a minor, with diagnosis that included post-traumatic stress disorder, was placed in seclusion on 10/2/22 for 40 minutes.

Review of the "Seclusion/Restraint Monitoring", was blank and revealed the Patient #7's response to the seclusion was not documented.

Patient #8

Review on 10/11-12/22 of Patient #8's record revealed patient was a minor, with diagnosis that included attention deficit hyperactivity disorder, was placed in seclusion on 10/2/22 for 40 minutes.

Review of the "Seclusion/Restraint Monitoring", was blank and revealed the Patient #8's response during the seclusion was not documented.

Patient #9

Review on 10/11-12/22 of Patient #9's record revealed patient was a minor, with diagnosis that included post-traumatic stress disorder, was placed in seclusion on 10/2/22 for 55 minutes.

Review of the "Seclusion/Restraint Monitoring", was blank and revealed the Patient #9's response during seclusion was not documented.


Patient #11

Review on 10/11-12/22 of Patient #11's record, a minor with diagnosis that included post-traumatic stress disorder, was placed in seclusion on 10/2/22 for 40 minutes.

Review of the "Seclusion/Restraint Monitoring", was blank and revealed the Patient #11's response during seclusion was not documented.

Patient #14

Review on 10/11-12/22 of Patient #14's record revealed patient was a minor, with diagnosis that included depression post-traumatic stress disorder, was placed in seclusion on 10/2/22 at 9:28 for 7 minutes and 75 minutes."

Further review revealed there were no nurses notes for 10/02/22 that further described the event.

During an interview on 10/11/22 at 3:48 PM when asked if he/she had received training from the facility on seclusion LN #2 stated "not from North Star Hospital", the LN stated he had received training from another hospital. The LN stated he was working on 10/02/22.


During an interview on 10/12/22 at 12:00 PM, Mental Health Specialist (MHS) stated he/she had completed the training on "Handle with Care", a training used for safely managing challenging and disruptive behavior that also teaches physical holds. The MHS stated he/she how to implement seclusion had not been included in the training. When asked how often patients were to be monitored when they were in seclusion, the MHS stated someone told him/her they need to be check on every 5 minutes and someone else stated every 15 minutes. MHS #2 stated he/she tries to check on the patients every 5 minutes. The MHS stated he/she had recently started working at the facility


During an interview with on 10/12/22 at 11:17 AM, the Director of Human Resources (DHR) stated not all of the employees on the nursing units had completed training for seclusion. She stated that they may have received in person training on the floor. DHR stated the facility planned to schedule a time for the employees to complete this.

Review on 10/13/22 of the facility policy titled, "Proper use and monitoring of Physical/Chemical Restraints and Seclusion - Acute", revised 4/22 revealed:

14.2 Training requirements for staff authorized to perform the 15-minute documented assessments or monitor patients (RNs, LVNs/LPNs, MHTs [mental health technicians]). Staff who are authorized to perform 15-minute assessments of and/or who monitor individuals in restraint/seclusion receive additional training and demonstrate competence in:
14.2.1 Taking vital signs and interpreting their relevance to the physical safety of the individual in restraint/seclusion, including respiratory status;
14.2.2 Recognizing nutritional/hydration needs;
14.2.3 Checking circulation and range of motion in extremities (restraint only);
14.2.4. Checking skin integrity (restraint only)
14.2.5 Addressing hygiene and elimination;
14.2.6 Addressing physical and psychological status and comfort;
14.2.7 Assisting individuals in meeting behavioral criteria for the discontinuation of restraint/seclusion; and
14.2.8 Identifying specific patient behavioral changes that indicate readiness for the discontinuation of restraint/ seclusion.
14.2.9 Recognizing signs of any incorrect application of restraints
14.2.10 Recognizing when to contact a medically trained LIP or emergency medical services in order to evaluate and/or treat the patient's physical status.
14.3 Training requirements for Registered Nurses: A registered nurse, in the absence of a physician is authorized to initiate restraint or seclusion use and perform evaluations/reevaluations of individuals who are in restraint/seclusion to assess their readiness for discontinuation or establish the need to secure a new order. In addition to the training outlined above, RNs will be trained and will demonstrate competence in:
14.3.1 Recognizing how age, developmental considerations, gender issues, ethnicity, and history or sexual or physical abuse may affect the way in which an individual reacts to physical contact;
14.3.2 Choosing the least restrictive intervention based upon an individualized assessment of the patient's medical and physical status/condition.
14.3.3 The use of behavioral criteria for the discontinuation of restraint or seclusion and how to assist individuals in meeting these criteria."

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Based on record review and interview the facility failed to ensure telephone orders were complete and signed promptly (within 24 hours) after initiation of restraints and/or seclusion for 5 patients (#7, 8, 9, 11, and 14). This failed practice created inaccurate medical records and patients being secluded and/or restrained without authenticated physician orders.

Findings:

Patient #7

Review on 10/06-12/22 of Patient #7's record revealed patient was a minor, with diagnosis that included post-traumatic stress disorder, was placed in seclusion on 10/2/22.

A verbal order for seclusion on 10/02/22 had been filled out, but not signed off by the physician.

Patient #8

Review on 10/11-12/22 of Patient #8's record revealed patient was a minor, with diagnosis that included attention deficit hyperactivity disorder, was placed in seclusion on 10/2/22.

A verbal order for restraint and seclusion on 10/02/22 was filled out and had not been signed by the physician.


Patient #9

Review on 10/11-12/22 of Patient #9's record revealed patient was a minor, with diagnosis that included post-traumatic stress disorder, was placed in seclusion twice on 10/2/22.

One 10/02/22 order did not indicate the intervention used (restraint and/or seclusion) and the if order was for seclusion, neither order had been signed by the physician.


Patient #11

Review on 10/11-12/22 of Patient #11's record revealed patient was a minor, with diagnosis that included post-traumatic stress disorder, was placed in seclusion on 10/2/22.

The intervention restraint and/or seclusion was not indicated, and the verbal order was not signed by the physician.

Patient #14

Review on 10/11-12/22 of Patient #14's record revealed patient was a minor, with diagnosis that included depression post-traumatic stress disorder, was placed in seclusion twice on 10/2/22.

The verbal orders for seclusion on 10/02/22 were not signed by a physician.

During an interview with QIRM (Quality Assurance/Risk Manager) on 10/07/22 at 12:22, when asked about the missing orders the QIRM stated some of the providers worked out of State and the orders had to be faxed back, She stated the providers administrative assistant usually helped the providers sign electronically. She stated they should have been signed the next day.


During an interview on 10/12/22 at 1:52 AM Psychiatrist #2 stated he/she remembered giving verbal orders for the seclusions on 10/02/22 because there were so many of them.

Review of the facility Policy and Procedure titled "Proper use and monitoring of Physical/Chemical Restraints and Seclusion - Acute", revised 4/22, revealed "The physician's order for use of restraint or seclusion will be recorded in the medical record and include the following ... The physician shall authenticate the telephone/verbal order within 24 hours."
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Based on observation, record review, and interview the facility failed to ensure the medical records contained all nursing notes and reports of treatment necessary to monitor the patient status for 6 patients reviewed (#7, 8, 9, 11, 13, and 14). This failed practice created an incomplete record of the patients stay in the hospital. Findings:

Observation during the survey on 10/7-13/22 revealed the facility used a paper charting system. Review of the charts on the units revealed they were tabbed with slips of paper and sticky notes.

Patient #7

Review of Patient #7's record on 10/10-13/22 revealed
Group Process Notes were missing for
9/04/22, 9/10/22, 9/11/22, 9/16/22, 9/17/22, 9/18/22 9/19/22 9/25/22 9/26/22 9/30/22 10/01/22, 10/02/22, 10/03/22

Group Notes for RT/AT [recreational therapy/art therapy] were missing for
9/02/22, 9/02/22 9/22/22, 10/02/22, 10/03/22, 10/04/22, 10/05/22

MHS Notes
9/27/22 and 10/04/22

Nursing Notes were missing for
9/02/22 both shifts
9/06/22 at 1900-700 unsigned note
9/19/22 at 1900 unsigned note
10/02/22 at 0700-1900
Patient #13

Review of Patient #13's medical record on 10/10/22 revealed:

Group Process Notes were missing for
9/11/22, 9/18/22, 9/23/22, 9/24/22, and 9/25/22

RT/AT Notes were missing for
9/16/22, 9/17/22, 9/20/22, 9/21/22

Review of Patient #s 8, 9, 11 and 14 revealed no nursing notes for 10/02/22 from 7:00 AM to 7:00 PM. A day that several seclusion events happened.

During an interview on 10/10/22 at 4:00 PM with the Chief Nursing Officer (CNO), was asked about the missing documents and the tabs of paper in the chart. The CNO stated medical records put those slips in so staff can go back and chart. The CNO stated any late charting should have been completed in 24 hours.
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